Clinical Case Conceptualization Research Articles

Medical traumatic stress: Integrating evidence-based clinical applications from health and trauma psychology.

Medical events in both childhood and adulthood, including components of the illness or injury and subsequent medical intervention, recovery, and disability, are increasingly being recognized as potentially traumatic. There has been an increased focus on scholarly work related to medical trauma and medically induced posttraumatic stress disorder (PTSD). Existing evidence suggests that trauma-focused treatment can promote both physical and psychological recovery. However, there continues to be a dearth of clinical guidance on how to (a) best identify and treat prior trauma exposure that complicates adjustment to illness and increases the risk for medically induced PTSD and (b) address medically induced PTSD while concurrently targeting health-related concerns (e.g., pain, adjustment to illness, acquired disability) that may negatively impact recovery. Originally presented as a premeeting institute at the 2023 Annual Meeting of the International Society for Traumatic Stress Studies, this paper describes the biopsychosocial impacts of medical trauma on adults and considerations for assessment and intervention in both traditional trauma and integrated care settings. This includes clinical applications, including assessment, case conceptualization, and health and rehabilitation interventions, that can promote health-related adjustment and coping within the context of trauma-focused treatment.

Multiple paths to rumination within a network analytical framework

Theories of rumination have proposed different psychological factors to place one at risk for repetitive negative thinking. A comprehensive empirical test that captures the most relevant contributors to rumination is lacking. Building on influential self-regulatory and metacognitive frameworks, we modeled how key constructs in this context relate to ruminative thinking. 498 participants completed online questionnaires including indicators of rumination, metacognition, promotion goal orientation, effortful control, and depression. We estimated regularized partial correlation networks to investigate unique associations between the different constructs and followed these analyses up with directed acyclic graphs to identify potential pathways towards rumination. Results demonstrated that: (1) both self-regulatory and metacognitive factors were directly linked to rumination, amongst these were (2) positive beliefs, negative beliefs about uncontrollability and harm, cognitive self-consciousness, depression, effortful control, perfectionism, and (lack of) cognitive confidence, and (3) we identified multiple directed pathways, suggesting three direct contributors to rumination while controlling for the influence of all other variables: diminished effortful control, positive beliefs, and cognitive self-consciousness. This study is the first to comprehensively assess metacognitive and self-regulatory frameworks of rumination in a data-driven manner. Our findings suggest that there are multiple pathways towards rumination, which should be incorporated in clinical case conceptualization of rumination and related disorders.

The social-cognitive clinician: On the implications of social cognitive theory for psychotherapy and assessment.

We review Bandura's contributions to cognitive-behavioural theory, research and practice. His basic research on the causal role of cognitive processes in social learning was a major factor in the emergence of cognitive-behavioural therapies in the 1970s. His investigations on observational learning and self-efficacy beliefs led to the development of guided mastery therapy, a specific cognitive-behavioural intervention for anxiety disorders. His research on self-regulatory processes provided an empirical basis for the emergence of numerous therapies targeting self-regulation. We conclude by discussing how Bandura's social cognitive theory, as well as more recent advances in social cognitive theorising, might be further applied to innovative approaches to therapeutic interventions, assessment and clinical case conceptualization.

The social determinants of mental health and professional counseling: A call to action

AbstractWe live in a complex and interconnected world with individual‐ and community‐level development and well‐being shaped by numerous variables. Given this multi‐deterministic nature of development, counselors are called to integrate the social determinants of mental health (SDMH) into key activities including clinical assessment, case conceptualization, treatment planning, prevention programming, education and training, and scientific inquiry. We discuss the consistency between the humanistic roots of the counseling profession with its values for developmental, preventative, and wellness‐oriented care and practices associated with the integration of the SDMH. We also provide a supportive rationale for the integration of SDMH into counseling practice through review of several key concepts: (a) upstream, midstream, and downstream influences on mental health; (b) the social gradient of mental health; (c) integrating population‐level perspectives on mental health and mental illness; (d) the functional roles of protective and risk factors; and (e) embodying a justice‐ and equity‐focused orientation.

Trauma-informed and affirmative mental health practices with LGBTQ+ clients.

People with diverse sexual orientations, gender identities, and gender expression are at greater risk for trauma, discrimination, and victimization than heterosexual and cisgender populations. Trauma-informed care (TIC) provides a framework for providing lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ +) mental health services. Substance Abuse and Mental Health Services Administration (SAMHSA)'s principles of TIC guide practitioners to create safety, trust, transparency, collaboration, and empowerment in helping relationships, and to ensure that services have cultural and gender relevance. This article first explores the role of trauma in contributing to behavioral health concerns presented by LGBTQ + clients. The application of TIC to mental health counseling and social services for LGBTQ + clients will then be described, with specific suggestions for translating TIC principles into affirmative practice. Through the lens of trauma, clinicians can improve clinical case conceptualization and effective treatment strategies for LGBTQ + clients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Wright-Constantine Structured Cultural Interview and Integration of Culture Into Case Conceptualization

Although multicultural counseling competence is crucial to the field of counseling psychology and clinical assessment, there remains a gap in how cultural data can be collected and used in clinical case conceptualization. The present study evaluated the case conceptualizations of doctoral-level trainees and focused on whether the integration of culture into the conceptualizations/formulations was influenced by the use of the Wright-Constantine Structured Cultural Interview (WCSCI), as compared to the use of one of two other cultural interviews (the Patient Cultural Identity Assessment and the DSM-5 Cultural Formulation Interview). Unsurprisingly, clients with minoritized identities and supervisors (but not trainees) with minoritized identities produced case conceptualizations that integrated culture at higher rates. Further, those conceptualizations that utilized the WCSCI were around 3.5 to 4.5 times more likely to integrate culture than those that used one of the other two cultural interviews. Implications for psychology practice are discussed.

Longitudinal course of mental health symptoms among veterans with and without cannabis use disorder.

Cannabis use disorder (CUD) is the most common non-alcohol related substance use disorder (SUD) in the United States and is especially prevalent among returning veterans. The long-term mental health correlates of CUD remain unknown, which is significant given the rise in legalization and also recreational and medicinal cannabis use nationally. Using a gender-balanced, national sample of 1,649 veterans (n = 115 with CUD; 75.2% White; M age = 37.49, SD = 9.88), we used latent growth curve modeling to examine posttraumatic stress disorder (PTSD) symptom severity, depressive symptoms, generalized anxiety, alcohol use, and psychosocial functioning between veterans with versus without a prior diagnosis of CUD over five time points, spanning an average of 7 years. Returning veterans with CUD compared to those without reported higher alcohol use, depression, anxiety, PTSD symptom severity, and worse psychosocial functioning at baseline. We observed nonlinear change across each outcome. We also found that CUD moderated change in alcohol use (quadratic: b = -.129, p < .001) and PTSD symptoms (quadratic: b = -.280, p = .019), such that individuals with CUD evidenced decelerated change and worse outcomes relative to veterans without a previously documented CUD diagnosis. Trajectories of depression, anxiety, and psychosocial functioning were similar across individuals with versus without CUD. In the first long-term and longitudinal evaluation of mental health and alcohol use course among returning veterans, CUD was associated with worse and more persistent alcohol use and PTSD symptom severity over time. These data have implications for clinical assessment, case conceptualization, and treatment of veterans and may inform efforts to offset risk for hazardous drinking and PTSD following a diagnosis of CUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"I put a stone on my heart and kept going": An explanatory model of how distress is generated and regulated among Indian women from slums reporting gender-based violence.

Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.

Deliberate Context-Driven Conceptualization in Psychological Assessment

Clinical formulation and case conceptualization in clinical psychological assessment typically organize a client’s presenting problems within a psychological framework and narrative that explains the cluster of symptoms, etiological and maintenance factors, and explaining both how and why a client is struggling or suffering. However, many of the most commonly used models of case conceptualization, as well as the preponderance of tests and measures used in psychological assessment, minimize or ignore the impacts of contextual factors, including dominant culture’s expectations for normative behavior and the client’s history of trauma and adverse and negative events. This paper presents a rationale and model for encouraging psychologists conducting clinical psychological assessment to be deliberate in first considering contextual factors in case conceptualization before relying entirely on primarily intrapsychic models. While contextual conceptualizations will not always replace (or join) intrapsychic models of case formulation, being deliberate and explicit about at least considering them is an important way to mitigate some of psychologists’ biases and has the potential to situate a narrative of client difficulties in a way that takes at least some of the burden off the client.

Unification: The Fifth Pathway to Psychotherapy Integration

Unified psychotherapy is an emerging trend in psychotherapy integration. This paper describes how and why unification constitutes a fifth pathway in the psychotherapy integration literature, and it delineates its key elements, and how it is practiced. The defining feature of unification is that it adopts a metatheoretical perspective that allows for the major psychotherapy paradigms and their interrelations to be seen from a more comprehensive vantage point. Such approaches facilitate holistic understandings of patients and treatment. The practice of unified psychotherapy includes comprehensive assessment, clinical case conceptualization and problem formulation, treatment planning and monitoring, and core principles for effective practice.

Assessing the utility of the Clinical Behavioral Case Conceptualization categories: A contextual behavioral based formulation model

Case conceptualization is a basic assessment tool in evidence-based clinical practice. Over the years, an extensive number of case conceptualizations have been developed; however, only a small number of those models met high-quality criteria in terms of validity and reliability. The Clinical Behavioral Case Conceptualization (CBCC) has shown good content and construct validity, as well as some preliminary evidence in treatment utility. Nonetheless, a further examination of CBCC categories' utility in identifying key explanatory processes by therapists is needed. Three independent raters assessed 171-case conceptualizations to establish whether CBCC descriptive (problem description) and explanatory categories (predisposition, precipitants acquisition, and maintenance) facilitate organizing and explaining clinical cases. Reviewers' consensus on the contribution of each category to clinical conceptualization was calculated by the Light's Kappa index. Findings indicated that CBCC descriptive and explanatory categories were significantly useful, with the exception of the precipitants category. In addition, acquisition and maintenance were the main categories that reviewers found as helpful in explaining clinical cases in the sample studied. We discuss CBCC utility for designing and establishing behaviorally oriented interventions and present methodological recommendations for future research on CBCC quality and ecological validity.

Validation of the UCLA PTSD Reaction Index for DSM-5: A Developmentally Informed Assessment Tool for Youth.

To describe the test construction procedure and evaluate the internal consistency, criterion-referenced validity, and diagnostic accuracy of the Child/Adolescent Self-Report Version of the UCLA PTSD Reaction Index for DSM-5 (RI-5) across 2 independent samples. Study 1 examined the clarity, developmental appropriateness, acceptability of individual RI-5 items, and internal consistency and criterion-referenced validity of the full test. The study 1 sample included 486 youth recruited from 2 major US cities who completed the RI-5 and a measure of depression. Study 2 evaluated the reliability and diagnostic accuracy of the RI-5 in 41 treatment-seeking youth who completed the RI-5 and a "gold standard" structured diagnostic interview, the Clinician-Administered PTSD Scale for DSM-5-Child/Adolescent Version. RI-5 total scale scores showed excellent internal consistency in the 2 samples. Study 1 provided evidence of criterion-referenced validity, in that total scale scores correlated positively with depressive symptoms. Study 2 provided evidence of diagnostic accuracy (including discriminant-groups validity). RI-5 total scores discriminated youth with from youth without PTSD as benchmarked against the structured diagnostic interview. Further, receiver operating characteristic analyses using a total score of 35 provided excellent diagnostic classification accuracy (area under the curve 0.94). The developmental appropriateness and diagnostic accuracy of the RI-5 support its utility for clinical assessment, case conceptualization, and treatment planning in different child-serving systems, including schools, juvenile justice, child welfare, and mental health.

Intersectionality, Intersubjectivity &amp; Integration: A Two Person Therapy

In this article I focus on the intersection of client and therapist experiences, and highlight the significance of reciprocity in the therapeutic relationship. Specifically, I attend to the process of joining and shared experience. I pay particular attention to contextual factors that shape the dynamics of interpersonal processes from a psychoanalytically informed framework—namely, Intersubjective Systems Theory (IST). From this vantage point, the interplay of client and therapist’s experiences of transference co-create an intersubjective system that, when acknowledged and attended to, creates the relational space for the client to explore his or her own “worlds of emotional experience” more fully (Stolorow, 2013). IST’s admonishment to attend to the contextual factors that shape the therapeutic relationship makes room for a broader, and deeper, form of clinical case conceptualization. A complimentary theory that has received increasing attention in the last two decades is intersectionality theory. Originally coined in the context of legal scholarship, intersectionality theory calls for a more holistic acknowledgement of, and appreciation for, the multiple factors (e.g. gender, race, religious affiliation) that shape personal identity, and the inextricable links that enable these factors to influence each other. Drawing on a clinical case, I highlight the ways that these theories can work together in a therapeutic relationship.

Cultural Components for Clinical Case Conceptualization of Emotionally Focused Couple Therapy with Korean Couples

Cultural Components for Clinical Case Conceptualization of Emotionally Focused Couple Therapy with Korean Couples

Wise Additions Bridge the Gap between Social Psychology and Clinical Practice: Cognitive-Behavioral Therapy as an Exemplar.

Progress in clinical science, theory, and practice requires the integration of advances from multiple fields of psychology, but much integration remains to be done. The current article seeks to address the specific gap that exists between basic social psychological theories and the implementation of related therapeutic techniques. We propose several "wise additions," based upon the principles outlined by Walton (2014), intended to bridge current social psychological research with clinical psychological therapeutic practice using cognitive behavioral therapy as an example. We consider how recent advances in social psychological theories can inform the development and implementation of wise additions in clinical case conceptualization and interventions. We specifically focus on self and identity, self-affirmation, transference, social identity, and embodied cognition, five dominant areas of interest in the field that have clear clinical applications.

Select models of cognition in developmental transformations: A theoretical integration

Recent theoretical and practical applications of drama therapy have incorporated cognitive models. This paper furthers this integration by presenting a specific drama-based therapeutic approach, developmental transformations, within a broader cognitive landscape. In proposing a cognitive model of developmental transformations (DvT) links to allied professions are established and clinical case conceptualizations are broadened with relevance to a larger mental health audience. An overview of DvT is provided followed by a rationale for a cognitive approach. Distinct elements of DvT practice are then broken down and elucidated within a cognitive framework. Questions posed and addressed include: What occurs cognitively when we encounter another person? What cognitive factors aid in maintaining an imaginary/dramatic reality? What cognitive processes facilitate transformation from one dramatic role to another? How can an embodied understanding of cognition contribute to DvT practice? In order to answer these questions components of the executive functioning system, associational networks, and models of information processing are implicated and applied to a DvT framework. As a result of identifying cognitive models within DvT, a research agenda for empirical investigation is promoted, inviting further identification and validation of cognitive models presented herein.

Relations Between Mindfulness Processes, Psychiatric Symptoms, and Functioning in Psychiatric and Pre-bariatric Surgery Outpatients

Mindfulness is increasingly an important part of clinical case conceptualization and treatment for mental illness. Although links between (1) mindfulness and psychiatric symptoms and (2) mindfulness and functioning are well-established, relatively few studies examine unique contributions of mindfulness to both symptoms and functioning concurrently. Moreover, we found few studies examining mindfulness, symptoms, and functioning using faceted measures of mindfulness. One thousand ninety-nine psychiatric outpatients and 1820 bariatric surgery candidates completed the Five Facet Mindfulness Questionnaire (FFMQ), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Structured Clinical Interview for DSM-IV (SCID-I), which also included items from the Schedule for Affective Disorders and Schizophrenia (SADS). Pearson correlations suggested four of five mindfulness facets (Observe, Act with Awareness, Nonjudge, Nonreact) related consistently to both psychiatric symptoms and functional outcomes in both the psychiatric and bariatric samples. In the psychiatric sample, Act with Awareness had an indirect effect on functioning, while Nonjudge and Nonreact had both indirect and direct effects on functioning and symptoms. In contrast, the bariatric sample showed direct and indirect effects of Act with Awareness, Nonjudge, and Nonreact on symptoms and functioning, and a single, direct effect of Observe on physical functioning. The fifth facet (Describe) was dropped from both models. Taken together, these results suggest that mindfulness facets vary significantly in their relation to psychiatric symptoms and functioning. Results have implications for conceptualizing mindfulness and mindfulness-based interventions in both clinical and research settings.

Social Cognitive Personality Assessment: A Case Conceptualization Procedure and Illustration

Although social cognitive theory has strongly influenced cognitive behavioral models of psychopathology and treatment, it has had far less influence on approaches to clinical personality assessment and case conceptualization. A primary obstacle has been the difficulty of translating social cognitive assessment principles into practical clinical assessment methods. The purpose of the present paper was to describe a cognitive behavioral case conceptualization procedure informed by a social cognitive personality assessment, one that the average cognitive behavioral therapist would be able to implement. To execute a social cognitive personality assessment, we argue that the clinician must perform four tasks: (a) identify personality structures, (b) identify if-then personality signatures, (c) map personality structures to if-then personality signatures, and (d) integrate social cognitive assessment data to form an evidence-based case conceptualization. For each of these four social cognitive personality assessment tasks, we describe an assessment procedure and then illustrate it using a case illustration of a depressed and anxious woman who presented at a psychology clinic. We conclude by discussing advantages, limitations, and possible future directions for further development of social cognitive personality assessment measures and case conceptualization procedures.

Thinking and working relationally: interviewing and constructing hypotheses to create compassionate understanding.

In the initial interviews of family therapy sessions, the therapist faces the challenge of obtaining and organizing the information that is most relevant toward understanding the essential concerns that families and couples bring to therapy. This article describes the process of clinical interviewing and case conceptualization used in training family therapists at the Ackerman Institute for the Family. This approach helps the therapist bring forward, and organize, specific information into relational hypotheses, or systemic-relational conceptualizations, that allow both family members and the therapist to understand presenting problems within their relational contexts. While always provisional, relational hypotheses help anchor the therapist in a systemic-relational frame and provide a conceptual through-line to guide the ongoing work of the therapy. The process of interviewing and the construction of clear and complex conceptualizations of presenting problems are illustrated through case examples.

Behavioral couple therapy: building a secure base for therapeutic integration.

Behavioral couple therapy (BCT), one of the two most empirically supported approaches to the treatment of couple discord, has undergone enormous changes in its four decades-long clinical and conceptual history. The evolution of thought about what maintains couple disaffection and distress and what can be done about it from a behavioral perspective is reviewed. These changes are considered in the larger context of the field of behavior therapy, noting shifts within BCT that parallel the three "waves" of development within that field. Integrative behavioral couple therapy (IBCT), the most visible and influential of the several BCT approaches, is examined, with particular attention to its functional-contextual base and the nature and role of functional analysis in clinical case conceptualization. It is argued that continuing enhancement and refinement of IBCT as an integrative therapeutic method will require greater flexibility in the techniques that are used and increased attention to the self of the IBCT therapist.